After a week’s hiatus for some rest and recuperation, coinciding with a trip to Europe, we return with our regular update from the Prepared Athlete Training and Health project. Following recent events, a post on the theme of injury management and return to performance seemed apt. It is also always helpful to articulate what role and functions I fulfill in this space. As a sports medicine physician I met up with this week remarked, ‘it must be a confusing for some people, as you are not a (medical) doctor or a physio’. Indeed my wife also asked this week what I call what I do in this space, as she was having a hard time explaining it to a friend of hers. So in this week’s offering I will attempt to clarify those questions as we outline the process and rationale for working with injured athletes and preparing them to return to performing.

BACK TO ‘WHAT IT IS YOU DO AGAIN’..?

As noted in the prologue, for some time what I do has not fitted easily into a pigeon hole, and this is intentional. Much like performance, sports injury does not respect boundaries, so my own learning and practice has been a series of deep dives directed towards thoroughly understanding whatever area was required (including pathology and sports medicine) to solve the particular problem at hand, rather than limiting my exploration to the confines of the conventional scope of whatever my job description happened to be at that time. As an aside, this is not dissimilar to the ‘performance therapy’ approach employed in more progressive environments, whereby the therapist, regardless of their specific discipline, equips themselves with a host of tools to best serve the athlete, as well as investing time to understand the sport, the technical model, and the specific nuances of those elements as they relate to each individual athlete.

To clarify, however, I am not a one-stop shop. I operate not just alongside, but in collaboration with the treating practitioner (be they sports medicine physician, physiotherapist, chiropractor, osteopath, etc.). My contribution seeks to complement the manual therapy and other treatment modalities that are provided by the treating practitioner. To reiterate: what I do does not replace the treatment and input provided by these highly qualified professionals in their respective disciplines.

As a collaborative process, all parties (including the athlete) work together to navigate the process, and it is a shared endeavour to problem-solve and come up with solutions. Not only is every athlete a different puzzle, each injury presents differently, so it is always a process of figuring out what is going on, and how best to proceed in each instance.

BEYOND TREATMENT…

It is important to recognise that manual therapy and other passive treatment modalities are just one part of the injury management and rehabilitation process. As anybody who has been treated for an injury will know, other aspects include rehabilitation exercises and gradual re-introduction of running and other activities that feature in the sport, perhaps involving some instruction, depending on the individual practitioner.

Essentially, the latter elements (i.e. training prescription and coaching input) are where I come in. As we will explore more fully, there are ways to support and direct the body’s natural healing processes, and we can adapt tools more readily associated with performance preparation to great effect here.

Another aspect that I provide for is modified workouts, adapted to the constraints imposed by the injury, which allows the athlete to continue to train and maintain a level of conditioning while they are out of action. This is critical, and is often overlooked outside of the professional sports environment - complete cessation of training is not good for the athlete or their mental state.

TRAINING AS TREATMENT…

Different modes of training, notably strength training, have in recent years become recognised in the sports medicine literature as an effective treatment modality for various musculoskeletal injuries and orthopaedic conditions. Different forms of resistance training are employed in the treatment of both acute injury and overuse injuries. For instance, strength training has become recognised as a front line treatment modality for different types of tendinopathy.

One of the major reasons that various forms of training constitute ‘treatment’ for different injuries is that it has an analgesic effect; that is, reduces pain and other symptoms. Similarly, appropriate use of conventional and modified training modalities serves to increase function. When used appropriately, training also serves to stimulate and direct healing and remodelling of injuried muscle, connective tissues, and even bone.

Advanced training modalities, including not only strength training, but also plyometrics, and other aspects of athletic preparation, can therefore play a major role during the rehabilitation process. Clearly these tools are also highly applicable in the arc that comes between rehabilitation under the direction of the treating therapist and returning to performing. As more progressive sports injury clinics are starting to recognise, this intermediate step is often a glaring gap that is not adequately provided for; and this helps explain why athletes find returning to training and competition following injury so problematic in many instances.

BE PREPARED…

Returning from injury, particularly more catastrophic injuries, is mentally very challenging, and there is naturally some degree of anxiety and aversion to overcome. This alone is a reason why injured athletes benefit from transitioning from therapist-led rehabilitation to working with a coach before they make their return. It is not necessarily that the treating practitioner lacks the knowledge to provide the necessary input and advanced training prescription, albeit these elements are also not covered in great detail during the standard schooling for most therapy disciplines. Rather there is a specific need to lengthen the leash, and reduce the dependency that can often develop between the athlete and the person who manages their initial care following the injury, which is understandably a vulnerable time for the athlete.

Successfully preparing injured athletes to return to performing also merits a more progressive approach than what is typical. The number one predictor of future injury is previous injury. By definition, when coming back from an injury the athlete is inevitably at greater risk than they were previously. It follows that returning the athlete to their pre-injury status is not sufficient. We need to ensure the athlete is stronger, more athletic, and better prepared than before, in order to offset the significant risk factor that the previous injury constitutes.

In effect we are seeking to create reserve capacity and extend failure limits as a buffer to protect against reinjury. We cannot do this without exposing the athlete to sufficient magnitude of training stimulus - hence the requirement for strength training and other ‘advanced’ training modalities. We are also looking to build capability, in order to find ways to better distribute stresses and make the athlete more efficient, as they are no longer likely to get away with mechanically unsound movement in the same way as they were able to prior to the injury. Practically this entails coaching and specific work on athletic movement to find ways to move that are more mechanically effective, and then dedicate time to enable the athlete to integrate these changes and apply movement strategies in the context of their sport.

So there it is. If any readers are able to sum that up in a catchy job description, all suggestions gratefully received..!

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